State gets OK to alter Medicare, Medicaid

Thursday

Dec 13, 2012 at 12:01 AMDec 13, 2012 at 12:28 PM

Federal regulators approved Ohio's plan to overhaul the way it provides health care to high-cost patients eligible for both Medicare and Medicaid yesterday. The aim is to improve care and save taxpayers an estimated $243 million by Dec. 31, 2016.

Catherine Candisky, The Columbus Dispatch

Federal regulators approved Ohio’s plan to overhaul the way it provides health care to high-cost patients eligible for both Medicare and Medicaid yesterday. The aim is to improve care and save taxpayers an estimated $243 million by Dec. 31, 2016.

Those enrolled in both Medicaid and Medicare are poor, elderly and disabled and tend to be among the sickest and most expensive to care for. Statewide, they make up 14?percent of the 2.2 million enrolled in Medicaid but account for 40 percent of total program spending.

Ohio is the third state — following Massachusetts and Washington — to win such approval from the Centers for Medicare and Medicaid Services and the second to use a managed-care approach. The federal government pays for Medicare and shares Medicaid costs with states.

“This agreement puts Ohio at the cutting edge of care coordination in the country,” Gov. John Kasich said in a statement. “Better care coordination across the state means healthier Ohioans, and it will also help in driving down costs in the long run.”

Under the state’s plan, Ohio will create an “Integrated Care Delivery System” to manage benefits and care for Medicare and Medicaid enrollees. The care includes long-term care, behavioral- and physical-health services such as doctor’s visits, prescription drugs and home-care services.

In August, the state awarded managed-care contracts worth up to $3.7 billion in Medicaid business alone to five health plans that will administer the program — Aetna Better Health of Ohio, Molina Healthcare, UnitedHealthcare Community Plan of Ohio, Buckeye Community Health Plan Inc. and Caresource. The plans will serve dual eligibles in the Columbus, Cincinnati, Cleveland, Akron-Canton, Dayton, Toledo and Youngstown areas.

Currently, there is very little coordination between Medicaid and Medicare operations, state officials say, and the result has been poor health outcomes for enrollees and high costs for taxpayers. The pilot program, they say, is the cornerstone of the state’s ongoing effort to improve access and quality while curbing costs.

For instance, state Medicaid Director John McCarthy said, dual eligibles currently must contact Medicaid for some services and Medicare for others. Under the new program, enrollees will have one point of contact for services. It also will require a pharmacist to be part of a patient’s care-co-

ordination team to avoid duplicate prescriptions and ensure that multiple prescriptions are filled on the same schedule.

“We believe the savings will come not in ratcheting down provider rates but getting the right care at the right time,” said Greg Moody, director of the Governor’s Office of Health Transformation.

Earlier this week, the federal government informed Ohio and other states that a partial expansion of state Medicaid programs will not qualify for additional federal matching funds promised through the federal health-care law.

The new law directed states to expand eligibility in their Medicaid programs to all individuals with annual incomes up to 133 percent of the federal poverty level — $30,656 a year for a family of four — and promised a 100 percent federal match to cover the additional costs from 2014 to 2016.

But after the U.S. Supreme Court tossed that requirement in a ruling last summer, Ohio and other states began to consider scaled-back expansion to 100 percent of poverty, and they recently asked whether the higher federal match would still be available.

“No” was the response sent to states this week by Health and Human Services Secretary Kathleen Sebelius. “The law does not provide for a phased-in or partial expansion.”

State officials said yesterday they won’t make any decision about expanding Medicaid before putting together the next two-year state budget, which will be unveiled by Kasich on Feb.?4.

“It is not ideal, when you are dealing with health policies, to distill down to all or nothing,” Moody said. “I am disappointed that was taken off the table by the federal government.”

The state first must determine how to cover the extra costs in 2014 and 2015 from those currently eligible for Medicaid who are expected to sign up to comply with the federal mandate that most Americans purchase health coverage starting in 2014 or pay a penalty.